Asystole and bradycardia related to anesthetic induction during ECT: a case report

Cardiac Arrest Upon Induction of General Anesthesia

There are numerous causes of cardiac arrest in the perioperative period, including hypoxia, hypovolemia, and vagal response to medications or procedures during routine anesthetics. Initiation of adequate cardiopulmonary resuscitation, administration of epinephrine, and application of a defibrillator, with shocking when applicable, are all essential steps in achieving return of spontaneous circulation. Knowledge and utilization of monitoring equipment can alert the provider to problems leading to cardiac arrest as well as ensure proper resuscitative efforts during the event. Polypharmacy is quite common with many of today's special needs patients. It is important to understand the medications they are taking as well as the potential interactions that may occur with drugs given during sedation and general anesthesia. The following is a case report of cardiac arrest including asystole and pulseless electrical activity in a 27-year-old man with autism and behavioral problems who presented for restorative dentistry under general anesthesia in the ambulatory surgery setting.

Flumazenil for Successful Seizure Induction With Electroconvulsive Therapy: Case Report and Literature Review

OBJECTIVE

Electroconvulsive therapy (ECT) is indicated for various psychiatric situations that are difficult to manage otherwise and may be regarded as a last resort but seizure induction is sometimes difficult, resulting in inadequate trials and futile outcomes.

METHOD

We report on a 72-year-old female patient with bipolar depression whose seizure induction with ECT was challenging but the use of flumazenil was deemed effective to obtain remission in the end. We also provide a literature review on this topic.

RESULTS

Seizure induction was managed with the use of flumazenil, a selective GABA-A receptor antagonist to neutralize the effects of benzodiazepine hypnotics, together with decreasing the amount of anesthesia, increasing the pulse width, and adding chlorpromazine. A PubMed search with keywords of flumazenil and ECT yielded only 14 hits (December 2020) and found some indication that flumazenil might be of use for this purpose even in the absence of benzodiazepines, although evidence base has remained very limited.

CONCLUSIONS

Flumazenil, an antidote of benzodiazepines, may be effective regardless of whether benzodiazepines are in use. Because inefficient ECT is clinically problematic, more studies are necessary to investigate the effectiveness of flumazenil for successful seizure induction with ECT.

Severe bradycardia at the termination of seizure during electroconvulsive therapy

BACKGROUND

Few cases of asystole or severe bradycardia occurring after the termination of seizure in the third phase with the dominance of parasympathetic nervous system activity during electroconvulsive therapy (ECT) have been reported. We describe a case of severe bradycardia occurring at the termination of seizure.

CASE PRESENTATION

The patient had been diagnosed with bipolar disorder more than 9 years earlier. No adverse hemodynamic events had been observed in over 100 sessions of ECT performed during a 9-year period. ECT was usually induced by propofol and suxamethonium. On this ECT, the heart rate gradually decreased before seizure termination, and severe bradycardia (5-6 beats/min) was identified lasting 15-20 s. Atropine administration immediately before electrical stimulus prevented any further bradycardia during the next session of ECT.

CONCLUSIONS

This case report indicates that attention should be paid to adverse cardiac events related to autonomic nerve activity even before such events occur during ECT.

Use of Succinylcholine by Anaesthetists in Turkey: A National Survey

OBJECTIVE

Although succinylcholine (SCh) has side effects, it is among the most commonly used muscle relaxants for rapid induction because of the faster onset of its effects and short effect duration. However, there is no information regarding the frequency of use of SCh by anaesthetists in Turkey. This study aims to investigate the use of SCh by anaesthetists working in Turkey.

METHODS

A web-based survey form was sent by e-mail to anaesthetists working in Turkey. The form comprised a total of 24 questions.

RESULTS

E-mails were sent to a total of 1882 addresses at two separate times. E-mail replies were received from 433 (23%) anaesthetists. Based on those who responded to the survey, 54.27% anaesthetists routinely used SCh for adult elective cases, 29.33% for paediatric elective cases and 74.13% for emergency cases. In adult elective cases, SCh was most frequently chosen for caesarean section (20.5%), and in paediatric elective and emergency cases, SCh was chosen most frequently because difficult intubation was expected (31.3 and 21.4%, respectively).

CONCLUSION

Our study reveals that SCh is still widely used by anaesthetists in Turkey. Majority of physicians who participated our survey were aware of the side effects; however, they reported using SCh in certain special situations. It is evident that creation of a standard care guide for departments is essential. The first stage of creating a standard care guide is to analyse and document the current application. With this aim, more wide-ranging advanced studies should be completed.

Pulseless electrical activity during electroconvulsive therapy: a case report

BACKGROUND

Arrhythmias resulting in cardiac arrest during electroconvulsive therapy have been reported. Most reported cases of cardiac arrest had asystole as the initial rhythm. Pulseless electrical activity as an initial rhythm of cardiac arrest during electroconvulsive therapy has never been reported. Also, thromboembolism after inflation of pneumatic tourniquet during lower limb surgery has been reported but never following tourniquet inflation during an electroconvulsive therapy.

CASE PRESENTATION

We report a case involving an 81- year- old female who presented to us for an electroconvulsive therapy for severe depression and developed pulseless electrical activity immediately after electroconvulsive therapy. She was successfully resuscitated and was later found to have bilateral pulmonary emboli with a complete occlusion of the right lower lobe pulmonary artery. The source of embolus was from her left lower extremity deep venous thrombus, which we believe, got dislodged intraoperatively after inflation of pneumatic tourniquet. Our patient not only survived the massive pulmonary embolus, but also showed significant improvement in her mental status compared to her pre-admission level at the time of discharge to a sub-acute rehabilitation centre.

CONCLUSION

We recommend that patients who are elderly and at high risk of thromboembolism should selectively undergo a preoperative doppler ultrasound for deep venous thrombosis. Also, selective application of tourniquet in the upper limb, to monitor for seizure activity, would reduce the incidence of pulmonary thrombo-embolism as embolic events are significantly less from deep venous thromboses of upper extremities when compared to lower extremities.

Severe bradycardia after anesthesia before electroconvulsive therapy

Postanesthesia bradycardia or asystole before electroconvulsive therapy (ECT) occurs very infrequently but is a potentially fatal complication of pre-ECT anesthesia. The optimal strategy for the prevention of its recurrence is unclear because the use of premedication with atropine may not always be successful. In this article, we present the case of a 21-year-old man with schizophrenia who developed bradycardia directly after receiving succinylcholine during the first 3 ECT sessions. Replacing succinylcholine with mivacurium seemed to be a successful strategy in preventing bradycardia during the final 9 ECT sessions.

Incessant non-sustained ventricular tachycardia after stimulus of electroconvulsive therapy with atropine premedication?

Electroconvulsive therapy (ECT) is an effective and safe treatment for a variety of neuropsychiatric disorders. Premedication with atropine has been recommended in order to avoid bradycardia and transient asystole induced by ECT. In contrast, some other arrhythmias can happen such as atrial flutter and fibrillation. But ventricular tachycardia is rare. Reported herein is a case of incessant non-sustained ventricular tachycardia, possibly triggered by atropine premedication.